Ch. 19 Flashcards
The nurse is caring for a client diagnosed with human immune deficiency virus. The client’s CD4+ cell count is 399/mm3. What action by the nurse is best?
a.
Counsel the client on safer sex practices/abstinence.
b.
Encourage the client to abstain from alcohol.
c.
Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors.
d.
Help the client plan high-protein/iron meals.
ANS: A
This client is in the Centers for Disease Control and Prevention stage 2 case definition group. He or she remains highly infectious and should be counseled on either safer sex practices or abstinence. Abstaining from alcohol is healthy but not required. Genetic testing is not commonly done, but an alteration on the CCR5/CXCR4 co-receptors is seen in long-term nonprogressors. High-protein/iron meals are important for people who are immunosuppressed, but helping to plan them does not take priority over stopping the spread of the disease.
DIF: Applying/Application REF: 328
The nurse is presenting information to a community group on safer sex practices. The nurse should teach that which sexual practice is the riskiest?
a.
Anal intercourse
b.
Masturbation
c.
Oral sex
d.
Vaginal intercourse
ANS: A
Anal intercourse is the riskiest sexual practice because the fragile anal tissue can tear, creating a portal of entry for human immune deficiency virus.
DIF: Understanding/Comprehension REF: 330
The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective?
a.
Consistent use of Standard Precautions
b.
Double-gloving before body fluid exposure
c.
Labeling charts and armbands “HIV+”
d.
Wearing a mask within 3 feet of the client
ANS: A
According to The Joint Commission, the most effective preventative measure to avoid HIV exposure is consistent use of Standard Precautions. Double-gloving is not necessary. Labeling charts and armbands in this fashion is a violation of the Health Information Portability and Accountability Act (HIPAA). Wearing a mask within 3 feet of the client is part of Airborne Precautions and is not necessary with every client contact.
DIF: Remembering/Knowledge REF: 332
A client with human immune deficiency virus is admitted to the hospital with fever, night sweats, and severe cough. Laboratory results include a CD4+ cell count of 180/mm3 and a negative tuberculosis (TB) skin test 4 days ago. What action should the nurse take first?
a.
Initiate Droplet Precautions for the client.
b.
Notify the provider about the CD4+ results.
c.
Place the client under Airborne Precautions.
d.
Use Standard Precautions to provide care.
ANS: C
Since this client’s CD4+ cell count is low, he or she may have anergy, or the inability to mount an immune response to the TB test. The nurse should first place the client on Airborne Precautions to prevent the spread of TB if it is present. Next the nurse notifies the provider about the low CD4+ count and requests alterative testing for TB. Droplet Precautions are not used for TB. Standard Precautions are not adequate in this case.
DIF: Applying/Application REF: 334
A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) antibodies. The test is negative and the client states “Whew! I was really worried about that result.” What action by the nurse is most important?
a.
Assess the client’s sexual activity and patterns.
b.
Express happiness over the test result.
c.
Remind the client about safer sex practices.
d.
Tell the client to be retested in 3 months.
ANS: A
The ELISA test can be falsely negative if testing occurs after the client has become infected but prior to making antibodies to HIV. This period of time is known as the window period and can last up to 36 months. The nurse needs to assess the client’s sexual behavior further to determine the proper response. The other actions are not the most important, but discussing safer sex practices is always appropriate.
DIF: Applying/Application REF: 336
A client with human immune deficiency virus (HIV) has had a sudden decline in status with a large increase in viral load. What action should the nurse take first?
a.
Ask the client about travel to any foreign countries.
b.
Assess the client for adherence to the drug regimen.
c.
Determine if the client has any new sexual partners.
d.
Request information about new living quarters or pets.
ANS: B
Adherence to the complex drug regimen needed for HIV treatment can be daunting. Clients must take their medications on time and correctly at a minimum of 90% of the time. Since this client’s viral load has increased dramatically, the nurse should first assess this factor. After this, the other assessments may or may not be needed.
DIF: Applying/Application REF: 338
A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort?
a.
Administer sleeping medication.
b.
Perform most activities for the client.
c.
Increase the client’s oxygen during activity.
d.
Pace activities, allowing for adequate rest.
ANS: D
This client has two major reasons for fatigue: decreased oxygenation and systemic illness. The nurse should not do everything for the client but rather let the client do as much as possible within limits and allow for adequate rest in between. Sleeping medications may be needed but not as the first step, and only with caution. Increasing oxygen during activities may or may not be warranted, but first the nurse must try pacing the client’s activity.
DIF: Applying/Application REF: 340
A client with HIV wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem?
a.
Chooses high-protein food
b.
Has decreased oral discomfort
c.
Eats 90% of meals and snacks
d.
Has a weight gain of 2 pounds/1 month
ANS: D
The weight gain is the best indicator that goals for this client problem have been met because it demonstrates that the client not only is eating well but also is able to absorb the nutrients.
DIF: Evaluating/Synthesis REF: 341
A client with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi’s sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important?
a.
Adhering to Standard Precautions
b.
Assessing tolerance to dressing changes
c.
Performing hand hygiene before and after care
d.
Disposing of soiled dressings properly
ANS: D
All of the actions are important, but due to the infectious nature of this illness, ensuring proper disposal of soiled dressings is vital.
DIF: Applying/Application REF: 342
A client has a primary selective immunoglobulin A deficiency. The nurse should prepare the client for self-management by teaching what principle of medical management?
a.
“Infusions will be scheduled every 3 to 4 weeks.”
b.
“Treatment is aimed at treating specific infections.”
c.
“Unfortunately, there is no effective treatment.”
d.
“You will need many immunoglobulin A infusions.”
ANS: B
Treatment for this disorder is vigorous management of infection, not infusion of exogenous immunoglobulins. The other responses are inaccurate.
DIF: Understanding/Comprehension REF: 345
An HIV-positive client is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate?
a.
Initiate Contact Precautions.
b.
Place the client on Airborne Precautions.
c.
Place the client on Droplet Precautions.
d.
Use Standard Precautions consistently.
ANS: D
Toxoplasma gondii infection is an opportunistic infection that poses no threat to immunocompetent health care workers. Use of Standard Precautions is sufficient to care for this client.
DIF: Applying/Application REF: 334
A client has just been diagnosed with human immune deficiency virus (HIV). The client is distraught and does not know what to do. What intervention by the nurse is best?
a.
Assess the client for support systems.
b.
Determine if a clergy member would help.
c.
Explain legal requirements to tell sex partners.
d.
Offer to tell the family for the client.
ANS: A
This client needs the assistance of support systems. The nurse should help the client identify them and what role they can play in supporting him or her. A clergy member may or may not be welcome. Legal requirements about disclosing HIV status vary by state. Telling the family for the client is enabling, and the client may not want the family to know.
DIF: Applying/Application REF: 343
A nurse works on a unit that has admitted its first client with acquired immune deficiency syndrome. The nurse overhears other staff members talking about the “AIDS guy” and wondering how the client contracted the disease. What action by the nurse is best?
a.
Confront the staff members about unethical behavior.
b.
Ignore the behavior; they will stop on their own soon.
c.
Report the behavior to the unit’s nursing management.
d.
Tell the client that other staff members are talking about him or her.
ANS: A
The professional nurse should be able to confront unethical behavior assertively. The staff should not be talking about clients unless they have a need to do so for client care. Ignoring the behavior may be more comfortable, but the nurse is abdicating responsibility. The behavior may need to be reported, but not as a first step. Telling the client that others are talking about him or her does not accomplish anything.
DIF: Applying/Application REF: 344
A client has been hospitalized with an opportunistic infection secondary to acquired immune deficiency syndrome. The client’s partner is listed as the emergency contact, but the client’s mother insists that she should be listed instead. What action by the nurse is best?
a.
Contact the social worker to assist the client with advance directives.
b.
Ignore the mother; the client does not want her to be involved.
c.
Let the client know, gently, that nurses cannot be involved in these disputes.
d.
Tell the client that, legally, the mother is the emergency contact.
ANS: A
The client should make his or her wishes known and formalize them through advance directives. The nurse should help the client by contacting someone to help with this process. Ignoring the mother or telling the client that nurses cannot be involved does not help the situation. Legal statutes vary by state; as more states recognize gay marriage, this issue will continue to evolve.
DIF: Applying/Application REF: 336
A client with human immune deficiency virus infection is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important?
a.
Consult with the pharmacy about drug interactions.
b.
Ensure that the client understands the new medications.
c.
Give the new drugs without considering the old ones.
d.
Schedule all medications at standard times.
ANS: A
The drug regimen for someone with HIV/AIDS is complex and consists of many medications that must be given at specific times of the day, and that have many interactions with other drugs. The nurse should consult with a pharmacist about possible interactions. Client teaching is important but does not take priority over ensuring the medications do not interfere with each other, which could lead to drug resistance or a resurgence of symptoms.
DIF: Applying/Application REF: 339
